1. Assisted Outpatient Treatment (W&I Code 5345) (AB 1421) “Laura’s Law” The Nevada County Experience May 7th, 2015 1

2. California enacted court-ordered outpatient treatment, known as Assisted Outpatient Treatment (AOT), as an option for Counties Modeled after Kendra’s Law in New York 45 states have similar laws Resulting from a collaboration with Treatment Advocacy Center, parents of victim, and state legislators 2 Jan 1, 2003

3. Not our intention to promote stigma of persons with mental illness We embrace recovery principles and the belief that all individuals can recover and live satisfying and productive lives We recognize that a small subset of persons with untreated mental illness, especially those with a co- occurring substance use disorder, may have a high potential to be dangerous to themselves or others 3 Stigma

4. AOT is too expensive AOT violates civil rights Voluntary treatment is more effective than AOT AOT is not needed because we already have other interventions (e.g. 5150 and 5350) 4 Issues to Consider

5. AOT allows forced medication AOT is not effective because you can’t force medication AOT outcomes are not documented AOT won’t work in counties with diverse cultural and ethnic populations 5 Issues to Consider

6. Lack of compliance with treatment, indicated by: 2/36 months; hospital, prison, jail or 1/48 months; serious and violence acts, threats, attempts to self /others (the element of dangerousness is a lower threshold than 5150 or 5350, not an imminent threat, not gravely disabled) 6 AOT Criteria

7. The person has been offered an opportunity to participate in treatment and failed to engage, or refused (therefore, voluntary services are not an alternative to AOT, as AOT requires that voluntary services have already been offered and refused) 7 AOT Criteria

8. These individuals do not pose an imminent danger to self or others, and do not meet WIC 5150 criteria These individuals are not gravely disabled, and so do not meet WIC 5350 criteria (i.e. Conservatorship) Therefore, simply attempting to hospitalize or conserve them is not a viable option 8 WIC 5150 and WIC 5350 Criteria-Not Met

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10. Community-based, multi-disciplinary treatment, 24/7 on-call support, mental health teams that use staff to client ratios of no more than 10 clients per 1 staff person Must include a Personal Service Coordinator (PSC) for full service coordination Team approach and capacity for frequent contacts For Example: Assertive Community Treatment (ACT) 10 AOT Program Requirements

11. Services that are client directed and employ recovery principles Integrated services that include mental health, substance abuse, physical health Self management of their illness, personal choice and self determination Benefit advocacy 11 AOT Program Requirements

12. Ongoing process; no set time limit Outreach to individuals, families, friends, health providers Emergency housing and health care Court order allows outreach to be possible to this population 12 Outreach

13. Access necessary health care Create and maintain a support system Live in the most independent and least restrictive housing option; transitional and permanent Work or other productive activity Reduce or eliminate contact with criminal justice system 13 Individualized Service Plans

14. Medication may be part of the court-ordered, individualized service plan Medications are not “forced”, but they are court- ordered Court-ordered treatment is commonly provided throughout the California mental health system Almost all participants take medication 14 No Forced Medication

15. Counties typically provide treatment to individuals with court orders for mental health treatment: LPS Conservatees Individuals on probation; mental health court Parents ordered into treatment in dependency court 15 Court-Ordered Treatment

16. Since May 2008: 82 referrals for AOT evaluations ; 67 unduplicated individuals 37 AOT court orders; 30 unduplicated individuals 6 incomplete orders due to hospitalization, incarceration, or death Approximately 6 people per year have received an AOT court order 16 Providence Center AOT Data

17. 5 adversarial hearings (i.e. where the person appeared with counsel and challenged the petition.) 4 hearings where the person did not appear; an evidentiary hearing was held before the judge to present the evidence that the person met criteria. 17 Providence Center AOT Data

18. Actual cost per individual varies; budget for Fiscal Year 14/15 projected at $20,736/year/individual = same as ACT Team cost Average length of stay is 180 days $1.81 is saved for every $1 invested Bill Medi-Cal, Medicare, private insurance, patient fees for allowable services AOT costs are similar to ACT costs 18 Costs and Savings

19. Psychiatric Hospital Days 510 days vs. 290 days post-treatment = 43.1% Incarceration Days 687 days vs. 327 days post-treatment = 52.4% Homeless Days 254 days vs. 117 days post-treatment = 53.9% 19 Actual Outcomes: For 19 unduplicated individuals, for the most recent 12 months pre-treatment vs. 12 months post-treatment

20. Satisfaction Rating: 72.4% MORS Extreme Risk 38.9% 6.5% MORS Coping/Rehabilitating 0.0% 40.0% 20 Actual Outcomes: For 19 unduplicated individuals, for the most recent 12 months pre-treatment vs. 12 months post-treatment

21. 3 components - Pre-hearing notice of investigation and hearing Court hearings and due process requirements Collaborative supervision of AOT after the court order Typical courtroom experience? 21 Court & Legal Process

22. County files a petition and the licensed mental health treatment provider may testify The petition must be served on: Person who is subject to the petition County Office of Patient Rights Current health care provider appointed The petition must determine there is no appropriate/feasible less restrictive option 22 Court & Legal Process

23. County provider must file an affidavit (declaration) with the court at 60-day intervals (or sooner if determined by the team and/or court) The declaration does not require a hearing, unless the court has set one in advance Affidavit reflects level of participation and whether the person continues to meet criteria. Includes individualized recommendations or modifications that may be discussed in court 23 Court & Legal Process

24. Nine California Counties are in various stages of implementation of AOT: Nevada, Yolo, San Francisco, Los Angeles, Placer, San Diego, Contra Costa, Mendocino, and Orange 45 states have adopted legislation to implement AOT AOT saves lives, protects civil rights, increases public safety, and improves the quality of life for the individual Provides treatment before an individual becomes gravely disabled, or does harm to self or others 24 Final Thoughts

25. AOT fills a gap in the treatment continuum AOT allows for a treatment option that is less restrictive than Conservatorship and locked inpatient care AOT is not a panacea, but does support the possibility of engaging some individuals in treatment that would not otherwise be possible It is possible to create a recovery based AOT program 25 Final, Final Thoughts

26. Michael Heggarty, MFT Nevada County Health and Human Services michael.heggarty@co.nevada.ca.us Carol Stanchfield, MFT Turning Point Providence Center Carolstanchfield@tpcp.org Honorable Judge Thomas Anderson Nevada County Superior Court Tom.Anderson@nevadacountycourts.com 26 Contact Information

27. Laura Wilcox 27